| NPI | 1871128926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: OH 191454) |
| Additional Taxonomies | 175T00000X Peer Specialist (Licence: OH 0001762) |
| Enumeration Date | 2020-03-10 |
| Last Update Date | 2025-03-27 |